nearenough - Therapy Thread

[nearenough]

Hi everyone,

I've been working with a sleep tech trying to dial in my settings.  From what they said, looking closely at the data reveals raspatory events that the machine (ResMed 11) don't always flag.  We came up with a plan to do several nights at a constant pressure (min = max) without EPR, then with EPR =3 to see which pressure would work best.  The results weren't fantastic, events (unflagged) persisted,  and it looked like we still needed to increase pressure.  Last night I had it set to 14, no EPR, and it was almost more than I could handle.  It was a real workout to exhale, my inner ears were pressurized, and I felt like I was ingesting more air than usual.  I woke up early in the morning and wasn't able to resume sleep without turning EPR back on.  Finally woke up exhausted, dry mouth (humidifier still had water), and a sore chest.  I missed the first couple hours of work when I fell back asleep without a mask on.

My question for you all - is it normal to have that kind of experience when increasing pressure?  Is higher pressure something eventually people acclimate to?  I was able to handle 12cmH2O fine, but 14 was a stretch.  However, the data still seems to show that higher pressure is needed, but it's daunting to think about another night like that.  

I'd love advice on handling the increase, and when or how to tell if it's too high.  Are there risk factors having pressure too high?

I've included a screen shot of min/max=12 (tolerated) and min/max = 14 (struggled) if that's at all helpful.  Feel free to ask for specific screen shots.

Thanks for your insights - I'd love to discuss your opinions and suggestions.

[staceyburke]

Your apnea is controlled. Youu is need to work on comfort. EPR is important for 2 reasons. First it make it easier - EPR is exhale pressure relief.

EPR also is important to limit flow limits. Flow limits are apnea.

I would suggest min 8
EPR 3 full time
Max 12

Look for how you feel not the number of events.

[nearenough]

That's an interesting take on it.  The sleep tech I'm working with would suggest it's not under control yet.  The raw numbers look good, but when you zoom in there's a lot of events that the device doesn't flag because they're not quite at the device's threshold.  Attached is a zoomed in series of events; many of which are not flagged by the device.  The OA events clearly show recovery breath after the de-crescendo.  

One of the things he's focusing on is arousal events.  Not necessarily an OA, CA, or H event, but clear patterns that would generally fall into RERA territory.  I have a lot of flow rate spikes that seem to indicate those consistently.

That said, if those are prevalent, does that change your opinion at all?

   

[Gideon]

None of your charts show EPR enabled. Please try that.
Also rest your charts to the standard view.
All 3 of your charts show flow limitations and you are doing nothing to treat them.

[nearenough]

Like I said, I did nights with EPR on and with it off.  I'll attach screenshots from 2 of those nights.  They show 12cm EPR=3 and 11cm with EPR=3.  

I'm also including last night's data.  I had pressure min/max set to 15, EPR=3.  It gave an AHI of zero.  Logged only 1 event; 0 flow limit.  It represents the best night I've had numerically (still judging how I feel). I will say, generally the pattern I see is having EPR turned on seems to give the best flow limit numbers. EPR off tends to put me in the 0.08 flow limit range.

I reset the charts to standard and oriented them as outlined in the board instructions.  Let me know if it's still incorrect.

12cm, EPR=3
   

11cm, EPR=3
   

15cm, EPR=3.  AHI = 0
   

[Gideon]

On future charts move flow limits above tidal volume.
Set a range 12-15. As we narrow in on your optimism. Definitely keep EPR=3, Fulltime as that is helping you. Technically you are treated, <5, and <3 so how you feel becomes important.b so critically state how you feel as we also look at your comfort.

[nearenough]

Thanks, Gideon.  Let me ask one quick clarifying question.  The sleep tech I worked with was really focused on minimizing arousals.  I realize without EEG it's a bit of a guessing game, but he found what looked to be tell-tale signs.  My question is, since the angle is to optimize for comfort, are those arousals, or unflagged events, detrimental to one's health? 

I'm confident I can find a good balance between comfort and treatment.  But I' would sacrifice comfort if I knew it would minimize the onset of comorbidities that sleep apnea so commonly causes.

That said, I was comfortable with every pressure up to and including 12cmH2O.  I went to 14 (no EPR) and it hit me hard as I described in the first post in this thread.  However I've been able to manage 15cm with EPR=3.  It seems like the 15cm range is providing effective therapy, and I'm willing to give it a go to see if I can acclimate.  

So, for a baseline, I'd say that the higher pressure seems to come with fatigue, but I only have 4 days of evidence at the 14/15 range.

[Gideon]

Post your daily chart. That helps more than you would believe.

[nearenough]

Fair enough.  Here's the most recent 3 nights.

Night 1 and 2 settings 
Min/Max=15, ERP=3

Night 3
Min=12, Max=16, EPR=3

Still dealing with fatigue in both configurations below.  I know some of that is due to adjusting to CPAP and fiddling with settings.  Nonetheless, the higher pressure seems to have fewer instances of CA events.


Min/Max=15, ERP=3, Night 1.  Zero AHI
   

Min/Max=15, ERP=3, Night 2.  0.84 AHI
   

Min 12, Max 16, EPR 3, Night 3.  1.39 AHI
   

[Gideon]

All 3 are awesome. The number of centrals is not significant in any of them. Of the 3 I'd prefer the 3rd, 12-16. That proves you do t need 15 as a max and max for you doesn't matter. You could set it to 20 with no change in your therapy. Either way you now have an early warming detection to look deeper if your pressure increases.

I'd even suggest trying 11 as a min pressure.

On AROUSALS, EPR=3 is your best defense. Increase in flow limits means your arousals are likely increasing. Yo know for sure would require a review of your flow rate at a 3-4 minute view.